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Pneumonia in the Elderly

Pneumonia in the Elderly. A Primer to Clinical Documentation WI ACDIS Chapter Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDIS. Pneumonia. Pneumonia- Infection of the aleveoli, distal airways, and interstitium of the lungs

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Pneumonia in the Elderly

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  1. Pneumonia in the Elderly A Primer to Clinical Documentation WI ACDIS Chapter Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDIS

  2. Pneumonia • Pneumonia- • Infection of the aleveoli, distal airways, and interstitium of the lungs • Inflammatory disease of the lung characterized by the production of a vascular response (hyperemia and vascular permeability) and an exudate • Caused by bacteria, viruses, fungi, and parasites • Typically classified as “community acquired” or “healthcare/hospital acquired”

  3. Pneumonia • Community Acquired Pneumonia- diagnosed outside the hospital or is diagnosed within 48 hours after admission to the hospital in a patient who has not been hospitalized in an acute care setting for 2 or more days within 90 days of the infection or has not been hospitalized or residing in a long term care facility for more than 14 days before the onset of symptoms. • Hospital Acquired Pneumonia/Nosocomial Pneumonia- acquired in hospital setting. Develops at least 48 hrs after hospital admission • Nursing Home Acquired Pneumonia- acquired in extended care setting.

  4. Hospital Acquired Pneumonia • HAP- • Carries highest morbidity and mortality rates of all nosocomial infections • Adds 7-9 days to hospital stays • Increases costs by $2 billion annually • Crude mortality rates range from 30 to 70% • HAP defined as new or progressive infiltrate on CXR plus at least two of the following: • Fever of > 37.8• C • Leukocytosis with >10,000 WBCs/uL • Production of purulent sputum • Dyspnea, hypoxemia, and pleuritic chest pain may occur

  5. Immunocompetent vs. Immunocompromised • Immunocompromised Patients • HIV disease • Absolute neutrophil count < 1000/mcL • Current or recent exposure to myelosuppressive or immonosuppressive drugs • Currently taking prednisone in dosage >5mg/d

  6. Clinical Presentation • Temperature > 38 •C(100.4F) • Cough with/without sputum, hemoptysis • Pleuritic chest pain • Myalgia • Gastrointestinal symptoms • Dyspnea • Malaise, fatigue • Rales, rhonchi, wheezing • Egophony, bronchial breath sounds • Dullness to percussion • Atypical symptoms in older patients

  7. Risk Factors Pneumonia Increased Morbidity & Mortality Overall Risk Factors • Advanced age • Alcoholism • Comorbid medical conditions • Altered mental status • Respiratory rate >=30 breaths/minute • Hypotension (systolic blood pressure < 90 mm Hg or diastolic < 60 mm Hg • Increased BUN • Age > 65 years • HIV or Immunocompromised • Recent antibiotic therapy or resistance to antibiotics • Comorbidities • Asthma • Cerebrovascular disease • COPD • CRF • CHF • Diabetes • Liver disease • Neoplastic disease

  8. Diagnosis of Pneumonia • Radiographic studies-CXR usually adequate, can have a auscultation-radiographic disassociation, may be negative in early phase of pneumonia • Lobar consolidation in typical pneumonia • Bilateral, more diffuse infiltrates commonly seen in atypical pneumonia • “Chest X-Ray Negative” pneumonia (dehydration, CHF, pulmonary fibrosis) • Blood cultures should precede antibiotic therapy • Positive in 6-20% of cases • Most commonly yielding S. pneumoniae (approx 60%), S. aureus or E. Coli • Sputum stain and culture • > 25 WBC and < 10 squamous adequate specimen • Sputum cultures only adequate in only 50% patients, only 44% of those samples contain pathogens • Single, predominant organism on Gram’s stain suggest etiology • Other stains indicated as appropriate (e.g., acid-fast stains for M tuberculosis, special stains for fungi or monoclonal antibodies stains for Pneumocystis

  9. Routes of Infection • Routes of infection • Aspiration of contaminated secretions-most common • Inhalation of infected airborne droplets • Bacteremia, and • Direct extension of an acute inflammatory process from an adjacent organ or structure

  10. Defense Mechanisms • In the normal respiratory system there are a number of important defense mechanisms that protect the lung from infection. These include: • Reflex closure of the vocal cords • Cough reflex • Mucociliary clearance • Macrophage activity

  11. Defense Mechanisms • Increased risk of bacterial infections associated with impairment of defense mechanisms, as in any of these clinical situations: • Loss of consciousness • Immunodeficiency state • Pulmonary edema • Neutropenia • Chronic airway obstruction • Viral infection

  12. Classification of Pneumonia • Classification of pneumonia • Causative organism • Pattern of anatomic involvement: lobar pneumonia or bronchopneumonia • Lobar pneumonia- exudative inflammation involving whole lobe, or large portion of lung • 90-95% cases caused by Streptococcus pneumoniae. Sometimes caused by Kleb pneumoniae, Staphylococcus, Streptococcus, H influenzae, or Gram negative bacteria • Bronchopneumonia • Characterized by focal areas of suppurative inflammation, in a patchy distribution, involving one or more lobes • Streptococcus pneumoniae is most common cause of community-acquired bronchopneumonia

  13. Complications of Pneumonia • Abscess formation • Spread of the infection to the pleural cavity (empyema) • Organization of the exudate (replacement of exudate by fibroblasts) • Bacteremia with spread of the infection to the distant sites

  14. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Streptococcus pneumoniae. Gram-positive diplocci • H influenzae. Pleomorphic gram negative cocbacilli • Chronic cardiopulmonary disease; follows upper respiratory tract infection • Chronic cardiopulmonary disease; follows upper respiratory tract infection

  15. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Staphylococcus aurerus. Plump gram-positive cocci in clumps • Klebsiella pneumoniae Plump gram-negative encapsulated rods • Residence in chronic care facility, hospital acquired, influenza epidemics, cystic fibrosis, bronchiectasis, injection drug use • Alcohol abuse, diabetes mellitus, hospital acquired

  16. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Escherichia Coli Gram-negative rods • Pseudomonas aeruginosa. Gram negative rods • Anaerobes Mixed flora • Hospital acquired; rarely community acquired • Hospital acquired, cystic fibrosis; cystic fibrosis, bronchiectasis • Aspiration, poor dental hygiene

  17. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Mycoplasma pneumoniae. PMNs and monocytes; no bacteria • Legionella species • Young adults; summer and fall • Summer and fall; exposure to contaminated construction site, water source, air conditioner; community-acquired or hospital- acquired

  18. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Chlamydophilia pneumoniae Non-specific • Clinically similar to M pneumoniae, but prodromal symptoms last longer (up to two weeks). Sore throat with hoarseness common. Mild pneumonia in teenagers and young adults

  19. Characteristics of selected Pneumonias Organism; Appearance on sputum Clinical Setting • Moraxella catarrhalis. Gram-negative diplcocci • Pneumocystis jiroveci. Non-specific • Preexisting lung disease; elderly; corticosteroid or immunosuppressive therapy • AIDS, immunosuppressive or cytotoxic drug therapy, cancer

  20. CDI Task • Know Thy Antibiotic Coverage and pharmacokinetics • Pay Attention to Minimum Inhibition Coverage values and antibiotic selection • Query for Clinical Clarification and Specificity when clinically appropriate • Clinical Relevance/Context is key

  21. Inpatient Admission Pneumonia • Hospitalization for pneumonia • Nursing home residents and older adults • Adults with any of the following: • Respiratory rate > 28/min • SBP <90 mmHg or 30 mm Hg below baseline • Altered mental status • Hypoxemia • Unstable comorbid illness • Multilobar pneumonia • Pleural effusion that is > 1 cm on lateral decubitus CXR & ahs characteristics of a complicated parapneumonic effusion on pleural fluid analysis

  22. Pneumonia Severity Index • Pneumonia Severity Index- Risk model to assist physicians in identifying patients higher risk of complications and more likely to benefit from hospitalization • Clinical guideline for physician management, supplemented by physician clinical judgment • CDIS- cognizance of severity index when contemplating pneumonia principal diagnosis selection with concomitant conditions.

  23. Pneumonia Severity Index Patient Characteristics Points Demographics • Male Age (years) • Female Age (years) – 10 • Nursing home resident + 10 Comorbid illness • Neoplastic disease + 30 • Liver disease + 20 • Congestive heart failure + 10 • Cerebrovascular disease + 10 • Renal disease +10

  24. Pneumonia Severity Index Physical examination findings • Altered mental status + 20 • Respiratory rate >30 breaths per minute + 20 • Systolic blood pressure < 90 mm Hg + 20 • Temperature < 35°C (95°F) or >40°C (104°F) + 15 • Pulse rate >125 beats per minute + 10

  25. Pneumonia Severity Index Laboratory and radiographic findings • Arterial pH < 7.35 + 30 • Blood urea nitrogen >64 mg per dL (22.85 mmol per L) +20 • Sodium < 130 mEq per L (130 mmol per L) + 20 • Glucose >250 mg per dL (13.87 mmol per L) + 10 • Hematocrit < 30 percent + 10 • Partial pressure of arterial oxygen < 60 mm Hg or oxygen percent saturation < 90 percent + 10 • Pleural effusion +10

  26. Pneumonia Severity Index Risk Class Recommended Site of Care Point Total Risk Risk lass No Low I Predictors <=70 Low II 71 to 90 Low III 91 to 130 Moderate IV >130 High V Mortality Recommend Site of care .1 Outpatient .6 Outpatient 2.8 Inpatient (briefly) 8.2 Inpatient 29.2 Inpatient

  27. Postoperative Respiratory Failure • National Quality Measures Clearinghouse Definition Acute Respiratory Failure • Acute Respiratory Failure in the secondary diagnosis field • 518.81- Acute respiratory failure • 518.84- Acute-on-Chronic respiratory failure • Discharges meeting the following criteria with 518.81 or 518.84 in secondary diagnosis field • Mechanical Ventilation for 96 consecutive hours or more - zero or more days after the major operating room procedure code • Mechanical Ventilation for less than 96 consecutive hours or undetermined - two or more days after the major operating room procedure code • Reintubation - one or more days after the major operating room procedure code

  28. Postop Respiratory Failure Codes • 518.5 Pulmonary insufficiency following trauma and surgery • New code 518.51 Acute respiratory failure following trauma and surgery • Respiratory failure, not otherwise specified, following trauma and surgery • Excludes: Acute respiratory failure in other conditions (518.81) • New code 518.52 Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery • Adult respiratory distress syndrome • Pulmonary insufficiency following: • surgery • trauma • Shock lung related to trauma and surgery

  29. Postop Respiratory Failure Codes • New code 518.53 Acute and chronic respiratory failure following trauma and surgery • Excludes: • Acute and chronic respiratory failure in other conditions (518.84) • 518.8 Other diseases of lung • See revisions for ICD-9 codes 518.81 and 518.82 and 518.84

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